http://emedicine.medscape.

com/article/1972482-overview#showall Overview The male urethra is a narrow fibromuscular tube that conducts urine and semen from the bladder and ejaculatory ducts, respectively, to the exterior of the body (see the image below). Although the male urethra is a single structure, it is composed of a heterogeneous series of segments: prostatic, membranous, and spongy.

Male urethra and its segments. Most proximally, the prostatic urethra is responsible for involuntary continence, transmission of semen into the common genitourinary tract, and the most common site of bladder outlet obstruction in the Western world. The membranous urethra is critical to voluntary continence and, because of its rigid attachments, is highly susceptible to injury in pelvic trauma. The spongy urethra is surrounded by the corpus spongiosum and forms the terminal conduit communicating with the outside of the body. Knowledge of male urethral anatomy is essential for all health professionals because urethral catheterization is one of the most commonly performed procedures in health care. The male urethra is susceptible to a variety of pathologic conditions, ranging from traumatic to infectious to neoplastic. Pathophysiologic variants of the urethra may have devastating consequences, such as renal failure and infertility. Gross Anatomy The posterior male urethra forms from the urogenital sinus (see the image below). This sinus derives from the endoderm-derived cloaca, which is separated from the anorectal canal by the growth of the urorectal septum in the fourth week of gestation. The spongy urethra is formed after the seventh week by tubularization of the urethral folds along the urethral groove under the influence of dihydrotestosterone. The most distal portion of the urethra is likely formed by invagination of an epithelial tag at the distal end of the genital tubercle.[1]

Embryologic development of pendulous urethra. The male urethra originates at the bladder neck and terminates at the urethral meatus on the glans penis. It is roughly 15-25 cm long in the adult and forms an "S" curve when viewed from a median sagittal plane in an upright, flaccid position (see the image below). The male urethra is often divided into 3 segments on the basis of its investing structures: prostatic urethra, membranous urethra, and spongy (or penile) urethra.

Male urethra and its segments. Other systems for naming the parts of the urethra have been described. The urethra can be separated simply into anterior and posterior urethra. The spongy urethra can be subdivided into fossa navicularis, pendulous urethra, and bulbous (bulbar) urethra. Finally, the bladder neck, or preprostatic urethra, can be classified as a distinct part of the urethra (see the image below).

Posterior wall of urethra. Prostatic urethra The prostatic urethra is the portion of the urethra that traverses the prostate. It originates in the region of the bladder neck, courses roughly 2.5 cm inferiorly, and terminates at the membranous urethra. It lies in a retropubic location and is bordered superiorly by the bladder and supported inferiorly by the sphincter urethrae externus muscle and the perineal membrane (formerly called the urogenital diaphragm). It is invested in the prostate, a glandular and fibrostromal organ that secretes seminal fluids and has clinical relevance. The urethra runs through the prostate eccentrically, with most of the prostatic tissue in a posterior and inferior location. The prostatic urethra is surrounded by an inner circular layer and an outer longitudinal layer of smooth muscle. The urethra forms an angle of roughly 45 (range, 0-90 ) at the midpoint of the prostatic urethra. The segment proximal to this location is surrounded by the involuntary internal sphincter. It is also the area most commonly affected by benign prostatic hyperplasia (BPH). The posterior wall of the prostatic urethra contains the urethral crest, which is bordered laterally by prostatic sinuses, into which the prostatic glands drain. The most prominent aspect of this crest is the seminal colliculus, or verumontanum, where the paired ejaculatory ducts and the opening of the prostatic utricle (a small midline paramesonephric duct remnant) meet the lumen of the urethra. The seminal colliculus has no functional significance but is a crucial landmark in urethroscopy and transurethral surgery. Membranous urethra The shortest and least distensible portion of the urethra is the membranous urethra. This region spans from the apex of the prostate to the bulb of the penis. It is invested in the external urethral sphincter muscle and the perineal membrane. The external sphincter is related anteriorly to the dorsal venous complex and is connected to the puboprostatic ligaments and the suspensory ligament of the penis. The external urethral sphincter muscle and the perineal membrane fix the urethra firmly to the ischial rami and inferior pubic rami, rendering this portion of the urethra susceptible to disruption with pelvic fracture. Spongy urethra The spongy urethra is the region that spans the corpus spongiosum of the penis. It is divided into the pendulous urethra and the bulbous (or bulbar) urethra. The pendulous urethra is invested in the corpus spongiosum of the penis in the pendulous portion of the penis. The urethra is located concentrically within the corpus spongiosum. In the distal urethra lies the fossa navicularis, a small dilation of the urethra just proximal to the urethral meatus. The meatus is a slitlike orifice with its long axis in a midline sagittal plane. The urethral meatus is slightly ventral to the tip of the penis. The bulbous urethra is invested in the bulb of the penis, the portion of corpus spongiosum that lies between the split corpora cavernosa in the superficial perineal space.

Bulbourethral (Cowper) glands, a male homologue of the greater vestibular (Bartholin) glands, originate in the external urethral sphincter muscle but terminate in ducts that empty into the bulbous urethra. The spongy urethra lies closer to the dorsum of the penis in the bulb. Vasculature and lymphatic drainage The prostatic urethra is supplied by the inferior vesical artery, which branches to penetrate the prostate and the bladder neck in superolateral positions. The bulbourethral artery supplies the membranous and bulbar urethra, whereas the pendulous urethra is supplied by the deep penile artery, a branch of the internal pudendal artery. In general, venous drainage mirrors the arterial supply. The prostatic and membranous urethra drain to the obturator and internal iliac nodes. Lymphatic drainage from the spongy urethra drains to the deep and superficial inguinal nodes.[2] Microscopic Anatomy The male urethra is a fibromuscular tube. It has distinct longitudinal folds that protrude into its lumen and make it readily identifiable on cross-section. The lining of the urethra varies from segment to segment but transitions from the urothelium of the bladder to the keratinized stratified squamous epithelium of the glans. The prostatic urethra is lined with transitional cell epithelium (urothelium). The membranous urethra is lined with stratified columnar and pseudostratified epithelium. Also, a rich vascular submucosa exists in the membranous urethra. Finally, the penile urethra is enclosed by the corpus spongiosum and lined with stratified columnar and pseudostratified epithelium with stratified squamous epithelium distally. The entire posterior urethra is lined with a submucosa and a series of muscular sphincters. The urethra is lined on the dorsal surface by the glands of Littre, which are concentrated more distally. Additionally, small diverticula, called lacunae of Morgagni, and a larger lacuna magna can be found at the fossa navicularis.[3] Pathophysiologic Variants Although the male urethra is subject to varying length and angulation, no common natural variants in urethral anatomy exist. Pathophysiologic variants include duplication, urethrorectal fistulae, congenital strictures, hypospadias, epispadias, and posterior or anterior urethral valves. Duplication Urethral duplication is a rare anomaly that typically occurs in the sagittal plane. Incontinence and infection are presenting symptoms; these anomalies can usually be picked up on newborn examination. A dorsal duplication is associated with a normal urethral meatus at the tip of the glans and an epispadiac urethra and dorsal chordee. The dorsal urethra may be blind-ended or associated with bladder exstrophy. Ventral duplication and duplication in the same horizontal plane are other variants of urethral duplication. Treatment is necessary if incontinence or infections are an issue. Fulguration or excision of the abnormal urethra is the standard therapy. Urethrorectal fistulae Urethrorectal fistulae are rare and are usually associated with imperforate anus. The signs of this are passage of stool and air through the meatus. Alternatively, in cases with a patent anus, urine may pass via the anus. Management of urethrorectal fistula in the presence of an imperforate anus involves either opening the anus and closing the fistula or fecal diversion if the distance between the blind-ended rectum and the perineum is too far for immediate reconstruction. Congenital strictures Congenital urethral strictures are rare but most commonly occur at the membranous urethra and fossa navicularis. They can be diagnosed with excretory urography, retrograde urethrography, or urethroscopy. Treatment involves direct-vision internal urethrotomy for membranous or fossa navicularis strictures or dilation for membranous strictures. Failure of endoscopic therapy warrants reconstruction. Hypospadias

Hypospadias is the most common urethral anomaly in males, occurring in 1 in 300 live births. In addition to a ventral ectopic urethral meatus, the typical physical findings include an incomplete dorsal hood appearance to the foreskin and a ventral chordee. Between the eighth and 15 th weeks of gestation, under influence of dihydrotestosterone, the urethral folds fuse, and the glans canalizes to form the urethra. Failure of this fusion may occur with in utero exposure to estrogens or progestins. Hypospadias is classified in severity according to the location of the failed fusion. Most cases of hypospadias are distal (ie, glanular or coronal). More proximal cases (ie, penile shaft, penoscrotal, or perineal hypospadias) may necessitate extensive and staged reconstructive efforts. The goal of treatment is to provide a functional penis that allows the boy to void while standing and deposit semen in the vagina. It is critical that boys with hypospadias are not circumcised in the newborn nursery; the extra foreskin may be used for reconstruction. Penoscrotal and perineal hypospadias are evidence of feminization and may indicate a need an evaluation for disorder of sexual differentiation.[4] Epispadias Epispadias is rare, occurring in 1 in 120,000 males. This pathologic variant results from failure of the genital tubercle to migrate appropriately in the fifth week of gestation. As a result, the urethral meatus is on the dorsum of the penis or at the penopubic junction. Proximal epispadias is often associated with incontinence and dorsal chordee. Severe epispadias may be associated with bladder exstrophy. Cosmesis is good with urethroplasty and correction of chordee, but continence is difficult to achieve surgically.[5] Posterior urethral valves Posterior urethral valves are thin membranes of mucosa in the distal prostatic urethra that cause varying degrees of obstruction when the child voids. They occur in 1 in 8,000 to 25,000 live births and are responsible for 10% of in utero diagnoses of obstructive uropathy. Antenatal ultrasonography is usually helpful in identifying clinically significant cases of posterior urethral valves, revealing a constellation of oligohydramnios, thickened bladder wall, full bladder, dilated posterior urethra, and bilateral hydroureteronephrosis. Management involves early drainage of the bladder, ablation of valves, and long-term management of bladder dysfunction and renal failure. Roughly 30% of boys progress to end-stage renal disease.[6] Anterior urethral valves Anterior urethral valves are far less common than posterior urethral valves. Unlike posterior urethral valves, they tend to manifest later in childhood, often with voiding symptoms or infection, and they have fewer long-term sequelae of hydronephrosis and renal failure. Typically, an anterior urethral valve is not a true valve but, rather, a diverticulum in the spongy urethra that balloons under the pressure of micturition; the distal edge of this diverticulum causes obstruction of the urethral lumen. Anterior urethral valves can be managed with transurethral ablation, but if they are associated with a large diverticulum, open excision may be necessary.

http://education.yahoo.com/reference/gray/subjects/subject/256 The Male Urethra (Urethra Virilis) 1

The male urethra (Fig. 1142) extends from the internal urethral orifice in the urinary bladder to the external urethral orifice at the end of the penis. It presents a double curve in the ordinary relaxed state of the penis (Fig. 1137). Its length varies from 17.5 to 20 cm.; and it is divided into three portions,

the prostatic, membranous, and cavernous, the structure and relations of which are essentially different. Except during the passage of the urine or semen, the greater part of the urethral canal is a mere transverse cleft or slit, with its upper and under surfaces in contact; at the external orifice the slit is vertical, in the membranous portion irregular or stellate, and in the prostatic portion somewhat arched. The prostatic portion (pars prostatica), the widest and most dilatable part of the canal, is about 3 cm. long, It runs almost vertically through the prostate from its base to its apex, lying nearer its anterior than its posterior surface; the form of the canal is spindle-shaped, being wider in the middle than at either extremity, and narrowest below, where it joins the membranous portion. A transverse section of the canal as it lies in the prostate is horse-shoe-shaped, with the convexity directed forward. 2

FIG. 1142 The male urethra laid open on its anterior (upper) surface. (See enlarged image)

Upon the posterior wall or floor is a narrow longitudinal ridge, the urethral crest (verumontanum), formed by an elevation of the mucous membrane and its subjacent tissue. It is from 15 to 17 mm. in length, and about 3 mm. in height, and contains, according to Kobelt, muscular and erectile tissue. When distended, it may serve to prevent the passage of the semen backward into the bladder. On either side of the crest is a slightly depressed fossa, the prostatic sinus, the floor of which is perforated by numerous apertures, the orifices of the prostatic ducts from the lateral lobes of the prostate; the ducts of the middle lobe open behind the crest. At the forepart of the urethral crest, below its summit, is a median elevation, the colliculus seminalis, upon or within the margins of which are the orifices of the prostatic utricle and the slit-like openings of the ejaculatory ducts. The prostatic utricle (sinus pocularis) forms a cul-de-sac about 6 mm. long, which runs upward and backward in the substance of the prostate behind the middle lobe. Its walls are composed of fibrous tissue, muscular fibers, and

mucous membrane, and numerous small glands open on its inner surface. It was called by Weber the uterus masculinus, from its being developed from the united lower ends of the atrophied Mllerian ducts, and therefore homologous with the uterus and vagina in the female. The membranous portion (pars membranacea) is the shortest, least dilatable, and, with the exception of the external orifice, the narrowest part of the canal. It extends downward and forward, with a slight anterior concavity, between the apex of the prostate and the bulb of the urethra, perforating the urogenital diaphragm about 2.5 cm. below and behind the pubic symphysis. The hinder part of the urethral bulb lies in apposition with the inferior fascia of the urogenital diaphragm, but its upper portion diverges somewhat from this fascia: the anterior wall of the membranous urethra is thus prolonged for a short distance in front of the urogenital diaphragm; it measures about 2 cm. in length, while the posterior wall which is between the two fasci of the diaphragm is only 1.25 cm. long. The membranous portion of the urethra is completely surrounded by the fibers of the Sphincter urethr membranace. In front of it the deep dorsal vein of the penis enters the pelvis between the transverse ligament of the pelvis and the arcuate pubic ligament; on either side near its termination are the bulbourethral glands. The cavernous portion (pars cavernosa; penile or spongy portion) is the longest part of the urethra, and is contained in the corpus cavernosum urethr. It is about 15 cm. long, and extends from the termination of the membranous portion to the external urethral orifice. Commencing below the inferior fascia of the urogenital diaphragm it passes forward and upward to the front of the symphysis pubis; and then, in the flaccid condition of the penis, it bends downward and forward. It is narrow, and of uniform size in the body of the penis, measuring about 6 mm. in diameter; it is dilated behind, within the bulb, and again anteriorly within the glans penis, where it forms the fossa navicularis urethr. The external urethral orifice (orificium urethr externum; meatus urinarius) is the most contracted part of the urethra; it is a vertical slit, about 6 mm. long, bounded on either side by two small labia. The lining membrane of the urethra, especially on the floor of the cavernous portion, presents the orifices of numerous mucous glands and follicles situated in the submucous tissue, and named the urethral glands (Littr). Besides these there are a number of small pit-like recesses, or lacun, of varying sizes. Their orifices are directed forward, so that they may easily intercept the point of a catheter in its passage along the canal. One of these lacun, larger than the rest, is situated on the upper surface of the fossa navicularis; it is called the lacuna magna. The bulbo-urethral glands open into the cavernous portion about 2.5 cm. in front of the inferior fascia of the urogenital diaphragm. 4

7 8

Structure.The urethra is composed of mucous membrane, supported by a submucous tissue which connects it with the various structures through which it passes.

The mucous coat forms part of the genito-urinary mucous membrane. It is continuous with the 1 mucous membrane of the bladder, ureters, and kidneys; externally, with the integument covering the 0 glans penis; and is prolonged into the ducts of the glands which open into the urethra, viz., the bulbourethral glands and the prostate; and into the ductus deferentes and vesicul seminales, through the ejaculatory ducts. In the cavernous and membranous portions the mucous membrane is arranged in longitudinal folds when the tube is empty. Small papill are found upon it, near the external urethral orifice; its epithelial lining is of the columnar variety except near the external orifice, where it is squamous and stratified.

The submucous tissue consists of a vascular erectile layer; outside this is a layer of unstriped 1 muscular fibers, arranged, in a circular direction, which separates the mucous membrane and 1 submucous tissue from the tissue of the corpus cavernosum urethr. Congenital defects of the urethra occur occasionally. The one most frequently met with is where 1 there is a cleft on the floor of the urethra owing to an arrest of union in the middle line. This is known 2 as hypospadias, and the cleft may vary in extent. The simplest and by far the most common form is where the deficiency is confined to the glans penis. The urethra ends at the point where the extremity of the prepuce joins the body of the penis, in a small valve-like opening. The prepuce is also cleft on its under surface and forms a sort of hood over the glans. There is a depression on the glans in the position of the normal meatus. This condition produces no disability and requires no treatment. In more severe cases the cavernous portion of the urethra is cleft throughout its entire length, and the opening of the urethra is at the point of junction of the penis and scrotum. The under surface of the penis in the middle line presents a furrow lined by a moist mucous membrane, on either side of which is often more or less dense fibrous tissue stretching from the glans to the opening of the urethra, which prevents complete erection taking place. Great discomfort is induced during micturition, and sexual connection is impossible. The condition may be remedied by a series of plastic operations. The worst form of this condition is where the urethra is deficient as far back as the perineum, and the scrotum is cleft. The penis is small and bound down between the two halves of the scrotum, so as to resemble an hypertrophied clitoris. The testes are often retained. The condition of parts, therefore, very much resembles the external organs of generation of the female, and many children the victims of this malformation have been brought up as girls. The halves of the scrotum, deficient of testes, resemble the labia, the cleft between them looks like the orifice of the vagina, and the diminutive penis is taken for an enlarged clitoris. There is no remedy for this condition. A much more uncommon form of malformation is where there is an apparent deficiency of the upper 1 wall of the urethra; this is named epispadias. The deficiency may vary in extent; when it is complete 3 the condition is associated with extroversion of the bladder. In less extensive cases, where there is no extroversion, there is an infundibuliform opening into the bladder. The penis is usually dwarfed and turned upward, so that the glans lies over the opening. Congenital stricture is also occasionally met with, and in such cases multiple strictures may be present throughout the whole length of the cavernous portion. http://emedicine.medscape.com/article/450903-overview#showall Background Urethral strictures arise from various causes and can result in a range of manifestations, from an asymptomatic presentation to severe discomfort secondary to urinary retention. Establishing effective drainage of the urinary bladder can be challenging, and a thorough understanding of urethral anatomy and urologic technology is essential. Consultation with a urologist should be obtained for any patient presenting to the emergency department with urinary retention secondary to urethral stricture disease.

Urethral

strictures.

Cross-sectional

diagram

of

the

penis.

Urethral strictures. Schematic of penile anatomy. History of the Procedure Urethral stricture disease has been cited as long ago as ancient Greek writings that reported establishing bladder drainage with the passage of various catheters. Historically, the treatment consisted of urethral dilation with sounds. Hamilton Russell described the first surgical procedure for repair of a urethral stricture in 1914. In contemporary times, several surgical options are available. Problem Urethral strictures can result from inflammatory, ischemic, or traumatic processes. These processes lead to scar tissue formation; scar tissue contracts and reduces the caliber of the urethral lumen, causing resistance to the antegrade flow of urine. The term urethral stricture generally refers to the anterior urethra and is secondary to scarring in the spongy erectile tissue of the corpus spongiosum. A posterior urethral stricture is due to a fibrotic process that narrows the bladder neck and usually results from a distraction injury secondary to trauma or surgery, such as radical prostatectomy. The focus of this article is anterior urethral stricture disease. Etiology The most common causes of urethral stricture today are traumatic or iatrogenic. Less-common causes include inflammatory or infectious, malignant, and congenital. Infectious urethral strictures are secondary typically to gonococcalurethritis, which remains common in certain high-risk populations. Pathophysiology Urethral strictures occur after an injury to the urothelium or corpus spongiosum causes scar tissue to form. A congenital stricture results from inadequate fusion of the anterior and posterior urethra, is short in length, and is not associated with an inflammatory process. This is an extremely rare cause. Presentation The most common presentation includes obstructive voiding symptoms, urinary retention, or urinary tract infections. Obstructive voiding symptoms are characterized by a decreased force of stream, incomplete

emptying of the bladder, urinary terminal dribbling, and urinary intermittency. These symptoms are progressive in many patients. Indications Surgical treatment of urethral stricture disease is indicated when the patient has severe voiding symptoms, bladder calculi, increased postvoid residual, or urinary tract infection or when conservative management fails. Relevant Anatomy The urethra is divided into anterior and posterior segments. The anterior urethra (from distal to proximal) includes the meatus, fossa navicularis, penile or pendulous urethra, and bulbar urethra. The posterior urethra (from distal to proximal) includes the membranous urethra and the prostatic urethra. The urethra lies within the corpus spongiosum, beginning at the level of the bulbous urethra and extending distally through the length of the penile urethra. The bulbar urethra begins at the root of the penis and ends at the urogenital diaphragm. The penile urethra has a more central position within the corpus spongiosum in contrast to the bulbous urethra, which is more dorsally positioned. The membranous urethra involves the segment extending from the urogenital diaphragm to the verumontanum. The prostatic urethra extends proximally from the verumontanum to the bladder neck. The soft-tissue layers of the penis, from external to internal, include the skin, superficial (dartos) fascia, deep (Buck) fascia, and the tunica albuginea surrounding the corpora cavernosa and corpus spongiosum. The superficial vascular supply to the penis comes from the external pudendal vessels, which arise from the femoral vessels. The external pudendal vessels give rise to the superficial dorsal penile vessels that run dorsolaterally and ventrolaterally along the penile shaft, providing a rich vascular supply to the dartos fascia and skin. The deep penile structures receive their arterial supply from the common penile artery, which arises from the internal pudendal artery. The common penile artery gives off several branches, including the bulbourethral, cavernosal, and deep dorsal penile arteries. The corpus spongiosum receives a dual blood supply via anastomoses between dorsal and urethral artery branches in the glans. The scrotum receives its vascular supply via branches from both the external and internal pudendal arteries.

Urethral

strictures.

Cross-sectional

diagram

of

the

penis.

Urethral strictures. Schematic of penile anatomy. Contraindications Urinary tract infections should be adequately treated prior to treatment. Malignancy should be ruled out with an endoscopic biopsy. Imaging Studies Urethral strictures are diagnosed based on a suggestive history, findings on physical examination, and radiographic or endoscopic techniques. The entire urethra, both proximal and distal to the strictured area, must be evaluated endoscopically and/or radiographically prior to any surgical intervention. Radiographic evaluation of the urethra with contrast studies is best achieved by retrograde urethrogram or antegrade cystourethrogram if the patient has an existing suprapubic catheter. Retrograde urethrograms and antegrade cystourethrograms are usually obtained through the radiology department, although the urologist can perform them directly. These studies can be used to diagnose and define the extent of the urethral stricture. Accurately documenting the extent and location of the stricture is important so that the most effective treatment options can be offered to the patient. The technical aspects of a retrograde urethrogram involve placing a nonlubricated 8F or 10F urethral catheter into the fossa navicularis and inflating the balloon with 1-3 mL of sterile water until the balloon occludes the urethral lumen. A scout film is obtained. Approximately 10 mL of iodinated contrast media is

then injected into the catheter under fluoroscopy, and images of the anterior urethra are taken. Extreme pressure during the injection phase can lead to extravasation and should be avoided. Do not mistake the membranous urethra for a stricture. On a retrograde urethrogram, the membranous urethra lies between the distal end of the verumontanum and the conical tip of the bulbous urethra.

Retrograde

urethrogram

demonstrating

bulbar

urethral

stricture.

Urethral

strictures.

Retrograde

urethrogram

demonstrating

complete

obliteration of the bulbous urethra.

Retrograde urethrogram demonstrating

pan-urethral stricture disease.

Urethral strictures. Retrograde urethrogram

demonstrating patent urethra after buccal mucosa urethroplasty. Urethral strictures. Retrograde urethrogram demonstrating patent urethra after excision of stricture and primary anastomosis. An antegrade cystourethrogram involves distending the bladder with water-soluble contrast media via a suprapubic tube or urethral catheter. A scout film is taken before administration of contrast material. Once the bladder is fully distended with contrast media, the suprapubic tube is clamped or the urethral catheter is removed and the patient is asked to void. Spot films are taken before, during, and after the voiding phase. This study can help delineate the posterior urethral anatomy. Ultrasonography of the male urethra can be useful in evaluating urethral strictures. A transducer can be placed longitudinally along the phallus, within the lumen of the urethra or along the perineum. Ultrasonography can be used to evaluate the stricture length and the degree and depth of spongiofibrosis. Several authors have described techniques that involve distension of the urethra with normal saline instilled in a retrograde fashion prior to ultrasonography. Ultrasonography demonstrates thicker periurethral tissues at the level of the stenosis compared to unaffected areas of the urethra. Ouattara et al (2004) showed that urethral strictures identified on perineal sonograms were significantly longer than those identified on retrograde urethrography and voiding cystourethrography.[1] A study by Zhang et al evaluated patients with conventional voiding and retrograde urethrography and 64row multidetector CT (64-MDCT) urethrography and found that 64-MDCT urethrography is a useful alternative to traditional radiographic methods for defining male urethral strictures.[2] Diagnostic Procedures Endoscopic evaluation can be conducted by flexible or rigid cystourethroscopy. Flexible cystourethroscopy can be performed with little discomfort to the patient using only local anesthesia, such as 2% lidocaine jelly intraurethrally. Medical Therapy There is no medical therapy to treat urethral stricture disease. Surgical Therapy Urethral dilation Some patients may opt to manage their stricture disease with periodic urethral dilations. The goal is to stretch the scar without producing additional scarring. It may be curative in patients with isolated epithelial strictures (no involvement of corpus spongiosum). Internal urethrotomy Internal urethrotomy involves incising the stricture transurethrally using endoscopic equipment. The incision allows for release of scar tissue. Success depends on the epithelialization process finishing before wound contraction significantly reduces the urethral lumen caliber. The incision is made under direct vision at the 12 o'clock position, either with a cold knife or urethrotome or a hot knife that uses electrocautery to cut through the scar tissue. Care must be taken not to injure the corpora cavernosa because this could lead to erectile dysfunction. Complications include recurrence of stricture, which is the most common complication, bleeding, or extravasation of irrigation fluid into perispongial tissues, thus increasing the fibrotic response. The curative

success rate is reported as 20%-35%, with no increase in the success rate with a second internal urethrotomy procedure. Typically, an indwelling urethral catheter is left in place for 3-5 days to oppose wound contraction forces and allow epithelialization. Longer periods of catheterizations have not been shown to reduce failure rates. Self-catheterization after internal urethrotomy has been used to improve cure rates by maintaining patency of the urethral lumen. However, strictures typically return once the patient stops.[3] Permanent urethral stents Permanent urethral stents are placed endoscopically. Stents are designed to be incorporated into the wall of the urethra and provide a patent lumen. They are most successful in short-length strictures in the bulbous urethra. Complications occur when a stent is placed distal to the bulbous urethra, causing pain while sitting or during intercourse. Other complications involve migration of the stent. This procedure is contraindicated in patients with dense strictures and in patients with prior substitution urethral reconstruction because it elicits a hypertrophic reaction. It may be best reserved for patients who are medically unfit to undergo lengthy open urethral reconstruction procedures.[4]

Urethral strictures. Photograph of a permanent urethral stent. Open Reconstruction Primary repair Primary repair involves complete excision of the fibrotic urethral segment with reanastomosis. The key technical points that must be followed include complete excision of the area of fibrosis, tension-free anastomosis, and widely patent anastomosis. Primary repair is typically used for stricture lengths of 1-2 cm. With extensive mobilization of the corpus spongiosum, strictures 3-4 cm in length can be repaired using this technique. Morey et al (2004) reported on a series of patients who underwent excision with anastomosis for strictures up to 5 cm.[5]Younger patients have more compliant tissue, thus allowing for greater stretch and more ambitious attempts at primary repair. The repair is left stented with a small silicone catheter in the urethra. The bladder is drained with a suprapubic catheter. Repairs involving tissue-transfer techniques

Technical points for free graft repair Success depends on the blood supply of local tissues at the site of placement. Pendulous urethral strictures may be repaired with the patient in the supine or split-legged position. Bulbar or membranous urethral strictures are repaired with the patient in the exaggerated lithotomy position. The urethra is exposed through a penile or perineal incision. The urethrotomy is made to open the area of the stricture. The tissue graft is harvested from the desired nonhair-bearing location. For example, bladder, buccal, or rectal mucosa are potential options. The graft is sutured to the edges of the urethrotomy. The graft is covered by the dartos fascia of the pendulous or bulbous urethra. Incisions are closed in 2 layers with an absorbable suture, and a Penrose drain is placed through a separate incision in the suprapubic or perineal areas. Full-thickness skin graft: Nonhair-bearing skin should be used. It is most successful in the area of the bulbar urethra. Split-thickness skin graft: The split-thickness skin graft is not preferred with a single-stage repair because of the contraction characteristics of the graft. It is typically reserved for use in patients for whom multiple procedures have failed and in whom local skin is insufficient for further reconstruction. It is conducted as a 2-stage procedure. First stage: The urethra is opened via a ventral midline incision down to the level of healthy urethra. The scarred urethra is excised completely. The dartos fascia is mobilized bilaterally and then closed in the midline over the scarred urethral bed. A split-thickness skin graft is harvested from a desired nonhair-bearing location. The graft is transferred to the ventrum of the penis and sutured to the dartos-

covered urethral bed, and the proximal aspect is anastomosed in a spatulated fashion to the proximal urethral stump. Xeroform gauze and Dacron padding are used to cover the graft and are secured with supporting sutures. A 14F soft silicone catheter is placed into the urethra and bladder for stenting. Urine is diverted with a suprapubic tube. The Dacron and Xeroform padding is removed after 5-6 days. The suprapubic tube is removed after 2 weeks. Second stage: Closure takes place in 6-9 months if the graft has succeeded. A 3-cmwide strip of skin is marked along the ventrum of the penis, which is to be used as the neourethra. A superficial, skin-deep incision is made along the marked lines. Care must be taken to spare the underlying dartos fascia. The skin strip is developed using the tissue plane between the penile skin and dartos fascia. The skin strip is fashioned into a neourethra as it is inverted using interrupted absorbable sutures. This is followed by a watertight closure using absorbable sutures in a running fashion. A small suction drain is left in the periurethral area, and the skin is closed. The drain is removed on postoperative day 3. A 14F soft silicone catheter is passed through the reconstructed urethra for stenting purposes.Urinary diversion is accomplished via a suprapubic tube for 3 weeks. Buccal mucosal graft: This tissue is resistant to infection and trauma. The epithelium is thick, making it easy to handle. The lamina propria is thin and highly vascular, thus allowing for efficient imbibition and inosculation. Harvesting is easier than with other free grafts or pedicled flaps. A 15- to 20-mm graft is harvested from the oral mucosa. Larger grafts can be harvested depending on the length of the stricture. Most surgeons prefer to close the buccal harvest site primarily. Care is taken to avoid the opening of the duct originating from the parotid gland. The duct for this salivary gland is also known as Stensen duct. The graft is sutured to the edge of the urethra. A Penrose drain is left in the incision bed for 24 hours to allow drainage. A 16F urethral catheter is left for 7 days. Suprapubic urinary drainage is continued for 2 weeks. The suprapubic tube is removed in 2 weeks, after voiding cystourethrogram demonstrates no extravasation of urine. The graft may be placed as a ventral, dorsal, or lateral onlay. Dorsal and lateral onlay procedures allow for the advantage of securing the graft to the corpora cavernosa (dorsal) or the ischiocavernosus muscle (lateral). This technique is performed with the hope of improving graft host bed immobilization and approximation. If a ventral urethrotomy and onlay are to be used, then a spongioplasty maneuver should be used to facilitate graft immobilization. This requires a relatively normal corpus spongiosum without fibrosis. Some reports have demonstrated superiority of the dorsal onlay

technique, whereas some data do not demonstrate a difference. [6] Urethral strictures. A buccal mouth graft has been harvested from the inner aspect of the cheek. The graft size is

measured to accommodate the length of urethra involved in the onlay. Urethral strictures. The buccal mucosal grafts have been secured to the corpora cavernosa. The anastomosis will run along either side of the dorsum of the urethral edges to complete the dorsal onlay. The glans penis (distal) is at the top of the picture. The catheterized urethra with a dorsal urethrotomy is on the left. Bladder mucosal graft: This is not as popular as other free tissue grafts because of difficulty in harvesting and handling the tissue.

Pedicled skin flaps These procedures are based on the principal of mobilizing an island of epithelium-bearing tissue with a pedicle of fascia to provide its own blood supply. Penile skin represents an ideal tissue substitute because it is thin and mobile and has an excellent blood supply. Moreover, the distal penile skin is typically nonhairbearing.

Skin island onlay flaps: Transverse, longitudinal, and circumferential island flaps refer to the type of skin incision made to fashion the tissue flap. Dorsal and ventral onlay refer to the position in which the flap is sutured to the edge of the incised urethra, as in the dorsal or ventral position with respect to the urethra and corpora cavernosa. Penile incision is carried out through the skin, dartos fascia, and down to Buck fascia. A skin island flap is elevated on the penile dartos fascia, which serves as the vascular supply. A lateral urethrotomy is made along the course of the strictured area. The skin island flap is then transposed to the incised strictured area, oriented into proper position, and sutured to the edges of the urethrotomy incision with an absorbable monofilament suture. A watertight subepithelial suture line should complete the flap placement. The skin is closed with interrupted sutures. Hairless scrotal island flap: A nonhair bearing area of skin in the midline of the scrotum is used. The tunica dartos of the scrotum is used as the vascular pedicle. This procedure typically is used in complex urethroplasty procedures and is combined with penile skin island flaps to provide additional vascularized tissue for reconstruction. Skin island tubularized flap: It can be used in combination with onlay flap when a large obliterated segment of urethra is present. It involves tubularizing the pedicled skin flap over a sound and

anastomosing the tubularized edge to the native urethral stump.

Urethral

strictures. Photograph of open urethroplasty depicting the pedicled flap. Urethral strictures. Photograph depicting pedicled flap anastomosed to the left side of the urethra. Suturing

of the right side of the pedicled flap to the urethra completes the anastomosis. Urethral strictures. The anastomosis of the pedicled flap is complete. The pedicle of the flap (left side) originates from the dorsolateral aspect of the penis. The glans penis (distal) is at the top of the photograph. Preoperative Details The patient should be evaluated and deemed medically stable for the selected procedure. Urine culture should be sterile. Urethral stricture disease should be thoroughly evaluated with radiographic and/or

endoscopic techniques. The procedure selection should be discussed thoroughly with the patient in advance, and the discussion should include information on the risks and benefits of the procedure and postoperative care. Risks include, but are not limited to, bleeding, infection, recurrence of stricture, and urethrocutaneous fistula formation. Intraoperative Details Position the patient in the supine, split-legged, or exaggerated lithotomy position. Take great care to pad pressure points and position joints to avoid inappropriate strain or torque. For open repair procedures, shave and prepare the perineum, penis, and scrotum. Administer intravenous antibiotics prior to making the incision.

Postoperative Details Patients are placed on bedrest for 24-48 hours, depending on the extent of the procedure. Intravenous antibiotics are continued for 24 hours and then followed with oral culture-specific antibiotics or antibiotics with good gram-negative coverage. Antimuscarinic agents are often used to prevent bladder spasms. Drains, if necessary, are typically removed on postoperative day 1-3. Wounds should be washed with soap and water daily after drains are removed. The patient may be discharged when afebrile, ambulatory, tolerant of a regular diet, and competent in managing drains, catheters, and wound care. Follow-up Patients undergoing internal urethrotomy should return to the outpatient clinic for catheter removal on postoperative day 3-5. Patients undergoing open repair should return to the outpatient clinic on postoperative day 3 for wound evaluation and removal of drains. Prior to removal of the suprapubic catheter, a voiding cystourethrogram is conducted with contrast, instilled through the suprapubic tube. If contrast extravasation is not evident and the suture line is intact, the urethral catheter is removed and the suprapubic tube capped. If the patient continues to void well, the suprapubic catheter is removed after 1 week. When all tubes are removed and no evidence of infection is present, antibiotics may be discontinued. Urethral evaluation should be conducted with retrograde urethrogram or flexible cystoscopy at 4 months and 1 year postoperatively. Complications Postoperative urinary tract infection and wound infections are rare complications of surgery to repair urethral strictures. Although there is no universal protocol for prescribing antibiotics postoperatively, most surgeons provide a short course of antimicrobials to minimize infections. Importantly, a sterile culture should be documented prior to bringing the patient to the operating room. In the event that a urine culture is positive for bacterial growth, culture-specific antibiotics should be prescribed prior to the procedure. Complications associated with individual procedures include the following:

Urethral dilation: Recurrence of the urethral stricture is the most common complication. Dilation of a urethral stricture is appropriate for patients with isolated epithelial strictures without scarring of the corpus spongiosum. Although rare, dilations can lead to urethral trauma caused by passage of the instrument through the urothelium into the corpus spongiosum or perispongial tissues. This risk can be minimized with careful technique and appropriate selection of patients for dilation. Internal urethrotomy: Recurrence of the stricture is the most common complication, with up to 80% of strictures recurring after an internal urethrotomy. Persistent postoperative bleeding can occur. The placement of a urinary catheter postoperatively provides intraluminal tamponade of superficial blood vessels. Extravasation of irrigation can precipitate a fibrotic response within the perispongial tissues. Permanent urethral stents: Distal migration of a urethral stent can lead to the complications of pain while sitting or during intercourse. Large multicenter studies have identified short-term risks of perineal discomfort and dribbling. Long-term risks include painful erections, mucous hyperplasia, recurring strictures, and urinary incontinence.

Open reconstructive techniques o Large series describing the use of an end-to-end anastomosis after excision of the strictured urethral segment report high success rates. Barbagli et al (2007) reported on a series of 153 patients undergoing this repair for bulbar urethral strictures. Most of the strictures were less than 2 cm in length. Ninety-one percent of patients responded after the single repair.[7] o Postoperative chordee and penile shortening after an excision and primary anastomosis is a concern. Appropriate patient selection and mobilization of the distal urethra may minimize these risks. Younger patients are less likely to experience these complications, as they have more compliant urethral tissue. o Other reported complications include ejaculatory dysfunction. Recent reports assert that sparing periurethral musculature such as the bulbospongiosus muscle can minimize postoperative ejaculatory dysfunction. Less commonly, decreased penile glans sensitivity, coldness of the glans during erection, and a glans that is not swollen during erection have been documented. o Onlay procedures use tissue transfer techniques, including skin flaps, rather than a graft, such as buccal mucosa. Complications include postvoid dribbling caused by postoperative diverticulum, retraction of the ventral skin of the penis, and urethrocutaneous fistula. Most experts agree that surgical technique and experience with tissue transfer techniques play a large role in maximizing outcomes and minimizing complications. o Oral complications after buccal mucosal harvesting: Buccal mucosal harvesting is an important tool in the urologists armamentarium in treating urethral stricture disease. The harvesting procedure is considered well-tolerated but does carry a risk of long-term complications. Several authors have monitored patients postoperatively after a buccal mucosal harvesting procedure. Oral pain over the harvest site resolves within the first month postoperatively. Persistent numbness, tightness, or coarseness over the harvest site has been reported in patients as late as 2 years postoperatively. Dublin and Stewart (2004) reported that 80% of patients who underwent urethroplasty with a buccal mucosal graft reported that they would undergo the same procedure again. [8] Most experts agree that the potential for long-term complications such as persistent neurosensory deficits and tightness, albeit rare, should be discussed with the patient preoperatively. Outcome and Prognosis Urethral dilation and internal urethrotomy A prospective randomized comparison of internal urethrotomy and urethral dilation for male urethral strictures found no significant difference in efficacy between the two procedures when used as initial treatment.[3] Recurrence rates increased as the length of the stricture increased. Recurrence rates at 12 months were 40%, 50%, and 80% for stricture lengths of less than 2 cm, 2-4 cm, and greater than 4 cm, respectively. The recurrence rate for strictures 2-4 cm long increased to 75% at 48 months of follow-up. Permanent urethral stents Five-year follow-up data demonstrated a long-term success rate of 84% and high level of patient satisfaction.[4] Failures typically occurred in patients with extensive stricture disease. The North American Study Group 11-year data demonstrated an overall success rate of less than 30%. [9] A European group reported 2 out of 15 satisfied patients 10 years postimplantation. [10] An Italian multicenter study following 94 cases reported on the short- and long-term complications. [11] Short-term complications (7-28 d following the procedure) included perineal discomfort (86%) and dribbling (14%). Long-term complications included painful erections (44%), mucous hyperplasia (44%), recurring stricture (29%), and incontinence (14%). Additionally, some unique complications are associated with permanently implantable stents. The stents are designed for placement within the bulbous urethra. If they are placed distally, there is a risk of pain upon sitting and intercourse. Excision with primary anastomosis This form of repair for anterior urethral strictures is considered to be the criterion standard. Historically, this technique has been reserved for strictures shorter than 2 cm. Better understanding of the anatomy has led to successful application of this repair to longer strictures. Jordan and Schlossberg (2007) reported 3 recurrences among 220 patients undergoing primary repair, with a mean follow-up period of 44 months.

[12]

Mundy (2006) performed an analysis of a large series of urethral reconstructions and described a durable rate after primary repair that does not deteriorate with time.[13] Free graft repair These procedures have an overall success rate of 84.3%. Mundy's analysis demonstrated a 95% success rate with graft reconstructions when the follow-up was limited to 1 year. Longer follow-up showed deterioration over time.[13] Pedicled skin flaps The overall success rate is 85.5%. Skin island onlay flap with preservation of the urethral plate provides better success rates than the tubularized flap. Tubularized island flaps have lower success rates than skin island onlay flaps secondary to stricture formation at the site of anastomosis with the native urethra.[14] A meta-analysis showed equivalent results when comparing graft versus flap reconstruction. [15] Many authors believe grafts are better suited for proximal reconstruction than flaps for distal reconstruction when all other variables are equivalent.[16] Postoperative erectile dysfunction Overall, the rates of erectile dysfunction after urethral reconstruction are low. Reported rates are as low as 2%.[12] Patients with severe straddle injuries were particularly at risk. A series of 200 patients who underwent anterior urethroplasties demonstrated that the rate of erectile dysfunction was comparable to that after circumcision. Patients who had longer segments of their urethra reconstructed were at higher risk. In this analysis, erectile dysfunction did improve over time.[17] A study to evaluate whether the type of one-stage urethroplasty has any influence on recovery from erectile dysfunction found that although the procedure has a probability of causing erectile dysfunction in as many as 20% of patients, the type of urethroplasty has no bearing on recovery, which generally occurs within 6 months.[18] Future and Controversies Many techniques are available for the treatment of urethral stricture disease. Based on the literature, each technique clearly cannot be applied successfully to every situation. Urologist who treats patients with urethral strictures must be experienced in several techniques. Each technique has advantages and disadvantages. Recently, buccal mucosa free graft urethroplasty has received favorable attention because of its excellent early results and decreased level of difficulty compared with those of pedicled skin flaps. So far, a prospective randomized study comparing free grafts with tissue flaps has not been conducted. The role of tissue engineering and stem cells in urethral reconstruction Tissue engineering incorporates the disciplines of cell transplantation, materials science, and engineering with the objective of creating functional replacement tissue. El Kassaby et al recently published a randomized comparative study of buccal mucosal and acellular bladder matrix grafts. An off-the-shelf matrix derived from the bladder was used. This biomaterial was obtained from donors and prepared via a multistep process, resulting in the removal of all cellular components. The tissue matrix that remains consists of collagen, elastin, growth factors, and macromolecules. Predicated on biocompatibility and the ability to recruit urethral tissue growth in several experimental and clinical studies, this matrix was used. With a mean follow-up period of 25 months in patients with a healthy urethral bed, the success rates for the acellular bladder matrix were similar to those using buccal mucosa. In patients who had undergone two or more prior urethral surgeries with significant spongiofibrosis, the success rate significantly deteriorated for the acellular matrix relative to buccal mucosa. This study demonstrates promise for the use of acellular matrices as a viable option for urethral repair in patients with a healthy urethral bed, no fibrosis of the corpora spongiosis, and good urethral mucosa.[19] The Wake Forest Institute for Regenerative Medicine recently published an article discussing the potential applications of stem cells in urology. Many of the successful experiments using stem cells for regenerative medicine have been within the field of urology using bladder, kidney, and urethral tissue. [20] Without

question, this is an exciting and interesting field that may revolutionize the way urethral stricture disease is treated in the future.

http://health.nytimes.com/health/guides/disease/urethral-stricture/overview.html Urethral stricture is an abnormal narrowing of the tube that carries urine out of the body from the bladder (urethra). REFERENCE FROM A.D.A.M. Back to TopCauses Urethral stricture may be caused by inflammation or scar tissue from surgery, disease, or injury. It may also be caused by pressure from an enlarging tumor near the urethra, although this is rare. Other risks include:

A history of sexually transmitted disease (STD) Any instrument inserted into the urethra (such as a catheter or cystoscope) Benign prostatic hyperplasia (BPH) Injury or trauma to the pelvic area Repeated episodes of urethritis Strictures that are present at birth (congenital) are rare. Strictures in women are also rare. Back to TopSymptoms

Blood in the semen Bloody or dark urine Decreased urine output Difficulty urinating Discharge from the urethra Frequent or urgent urination Inability to urinate (urinary retention) Incontinence Painful urination (dysuria) Pain in the lower abdomen Pelvic pain Slow urine stream (may develop suddenly or gradually) Spraying of urine stream Swelling of the penis Back to TopExams and Tests A physical examination may show the following:

Decreased urinary stream Discharge from the urethra Enlarged (distended) bladder Enlarged or tender lymph nodes in the groin (inguinal) area Enlarged or tender prostate Hardness (induration) on the under surface of the penis Redness or swelling of the penis Sometimes the exam reveals no abnormalities.

Tests include the following:

Cystoscopy Post-void residual (PVR) volume Retrograde urethrogram Tests for chlamydia and gonorrhea Urinalysis Urinary flow rate Urine culture Back to TopTreatment The urethra may be widened (dilated) during cystoscopy by inserting a thin instrument to stretch the urethra while you are under local anesthesia. You may be able to treat your stricture by learning to dilate the urethra at home. If urethral dilation is not successful or possible, you may need surgery to correct the condition. Surgical options depend on the location and length of the stricture. If the stricture is short and not near the urinary sphincter, options include cutting the stricture via cystoscopy or inserting a dilating device. An open urethroplasty may be done for longer strictures. This surgery involves removal of the diseased part followed by reconstruction. The results vary depending on the size and location, the number of treatments you have had, and the surgeon's experience. In cases of acute urinary retention, a suprapubic catheter may be placed as an emergency treatment. This allows the bladder to drain through the abdomen. There are currently no drug treatments for this disease. If all else fails, a urinary diversion -appendicovesicostomy (Mitrofanoff procedure) -- may be done. This allows you to perform selfcatheterization of the bladder through the wall of the abdomen. Back to TopOutlook (Prognosis) Treatment usually results in an excellent outcome. However, repeated therapies may be needed to remove the scar tissue. Back to TopPossible Complications Urethral stricture may totally block urine flow, causing acute urinary retention. This condition must be treated quickly. Back to TopWhen to Contact a Medical Professional Call your health care provider if symptoms of urethral stricture occur. Back to TopPrevention Practicing safer-sex behaviors may decrease the risk of getting sexually transmitted diseases and urethral stricture. Treating urethral stricture quickly may prevent complications such as kidney or bladder infection or injury.

http://emedicine.medscape.com/article/1893882-overview#showall Background Cystostomy is the general term for the surgical creation of an opening into the bladder; it may be a planned component of urologic surgery or an iatrogenic occurrence. Often, however, the term is used more narrowly to refer to suprapubic cystostomy or suprapubic catheterization. In a setting where an individual is unable to

empty his or her bladder appropriately and urethral catheterization is either undesirable or impossible, suprapubic cystostomy offers an effective alternative. Cystostomy for the purpose of suprapubic catheterization may be performed in 2 ways, as follows:

Via an open approach, in which a small infraumbilical incision is made above the pubic symphysis Via a percutaneous approach, in which the catheter is inserted directly through the abdominal wall, above the pubic symphysis, with or without ultrasound guidance or visualization through flexible cystoscopy This article focuses on the percutaneous approach because this method can potentially be performed in outpatient, bedside, or urgent care settings. Relevant Anatomy The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis. The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).

Gross anatomy of the bladder. For more information about the relevant anatomy, see Bladder Anatomy. See alsoFemale Urinary Organ Anatomy and Male Urinary Organ Anatomy. Indications At least 4 situations exist in which suprapubic cystostomy is considered: Acute urinary retention in which a urethral catheter cannot be passed (eg, because of prostatic enlargement secondary to benign prostatic hyperplasia or prostatitis, urethral strictures or false passages, or bladder neck contractures secondary to previous surgery) Urethral trauma Management of a complicated lower genitourinary tract infection Requirement for long-term urinary diversion (eg, because of neurogenic bladder) Acute urinary retention without urethral catheterization

For a patient who is difficult to catheterize transurethrally, various steps are suggested before suprapubic cystostomy is performed (see the image below).[1]

Algorithm for managing difficult-to-catheterize patient. Arrows indicate next reasonable step; horizontal lines indicate that either option is reasonable. Failure to pass a urethral catheter may result from a false passage created by multiple attempts at urethral catheterization or from urethral stricture disease. After a reasonable attempt at catheterization has been made, including use of a coud catheter, and if a urologist is not available to perform a flexible cystoscopy with potential catheter placement over a wire, a suprapubic cystostomy is reasonable. Urethral trauma In the setting of urethral trauma, functional bypass of the urethra may be required because of the possibility of urethral disruption. Urethral disruption is usually associated with pelvic fractures or saddle-type injuries and should be suspected when the triad of (1) blood at the urethral meatus, (2) inability to urinate, and (3) a palpably distended bladder is observed. The urethral injury should be addressed by a urologist; however, a suprapubic cystostomy may be a valuable measure for emergency drainage of the bladder. Complicated lower genitourinary infection In a complicated infection of the lower genitourinary tract (eg, acute bacterial prostatitis with urinary retention, urinary diversion with suprapubic cystostomy should be considered. A suprapubic catheter is necessary until the infection is fully treated with antimicrobials. Another indication for suprapubic catheter placement is the Fournier gangrene, which often necessitates multiple genitourinary debridement procedures and, potentially, skin grafting. A suprapubic cystostomy diverts the urine from these surgical sites very effectively. A urethral catheter would impede wound care and surgical management of this complicated, dangerous disease. Long-term urinary diversion

Suprapubic catheterization may also be considered as an option in patients who require long-term urinary diversion. The British Association of Urological Surgeons issued practice guidelines suggesting that clinicians should consider whether a suprapubic catheter would be preferable to an urethral catheter for patients who require a long-term indwelling catheter.[2] A suprapubic catheter may be considered in patients with neurogenic bladder secondary to spinal cord injuries, stroke, multiple sclerosis, neuropathy, or detrusor sphincter dyssynergia who are unable to void and who are unable or unwilling to perform clean intermittent catheterization.[3, 2] Patients who undergo phallic reconstruction or fistula repair [1] may also require longer-term urinary diversion. In a retrospective study that included more than 10 years of follow-up data from 179 predominantly male patients with spinal cord injuries, similar rates of urinary tract infections, bladder and renal calculi, and renal function preservation were reported for those managed with urethral catheters and those managed with suprapubic catheters.[4] In this study,[4] urethral strictures, urethral fistulas, and scrotal abscesses were found only in the urethral catheter group; 3 patients with urethral strictures and 3 patients with urethral-cutaneous fistulas switched to suprapubic catheters as a result of these complications. Catheter-specific complications included erosion associated with urethral catheters and leakage around the suprapubic catheter site and from the urethra. Contraindications Percutaneous suprapubic cystostomy is absolutely contraindicated in the following circumstances: The bladder is not distended, is not easily palpable, or cannot be localized with ultrasonographic assistance The patient has a history of bladder cancer Relative contraindications include the following:

Coagulopathy Previous lower abdominal or pelvic surgery (because of the possibility of adhesions between the bowel and the bladder) Pelvic cancer, with or without a history of irradiation (because of the possibility of adhesions) Placement of orthopedic hardware for pelvic fracture repair Although some reports suggest that suprapubic tubes leading to infection of hardware is a relatively rare complication, [5] consult with the orthopedist before performing suprapubic catheterization in patients with hardware If percutaneous placement is contraindicated and an open surgical approach to suprapubic cystostomy is necessary to provide appropriate dissection through adhesions, avoid bowel injury, and achieve effective hemostasis, this would probably have to be done by a general surgeon or urologist in an operative setting.[3]

Technical Considerations Procedural planning There are 2 key issues that must be kept in mind when placement of a suprapubic cystostomy is being considered. The first issue is whether the patients bladder can be sufficiently well drained with a urethral catheter. If this is the case, urethral catheterization may be a more appropriate choice because it is often easier and is associated with less short-term morbidity, especially in women and men who develop acute urinary retention and may regain the ability to void with straightforward medical management (eg, alphablocker therapy). On the other hand, suprapubic cystostomy may be preferable to urethral catheterization when the catheter is needed for long-term bladder management, as in patients with neurogenic bladders. For instance, male patients with a suprapubic cystostomy have a decreased incidence of traumatic hypospadias and a reduced risk of urinary tract infection, prostatitis, urethritis, and epididymitis. Male patients also retain sexual function. Female patients have a decreased incidence of urinary tract infection and can avoid development of a patulous urethra.

If the procedure can be planned in advance, referring the patient to a urologist for an informed discussion of elective procedures might be best. In those emergent situations where the patient is unable to empty his or her bladder and a urethral catheter cannot be placed, suprapubic cystostomy is a viable option. The second issue is the method that will be used to place the suprapubic cystostomy. As noted (see Background), either an open approach or a percutaneous approach to suprapubic catheterization may be taken. Most individuals with training in general surgery or urology find the open procedure straightforward. Most other physicians prefer a percutaneously placed suprapubic cystostomy, which can be performed by means of 5 different methods (see Technique). Unfortunately, the percutaneous option is not always available.

Complication Prevention

Regardless of how a suprapubic cystostomy is placed, it is always advisable to distend the bladder during localization of the surgical site. This affords the physician the best opportunity to find the bladder quickly and avoid bowel injury. In nonemergency circumstances, when the urethra cannot be cannulated and the bladder must be decompressed, the bladder probably is already distended with urine. If the urethra can be cannulated with a Foley catheter or a flexible cystoscope, the bladder can be distended with normal saline.To prevent gramnegative bacteremia, an appropriate preprocedural intravenous gram-negative antibiotic should be administered before instrumentation of the genitourinary tract.[3]

What are the symptoms? Usually the symptom starts with pain and difficulty in urination. The urine stream is very slow and may develop either suddenly or gradually: the urine output and urinary frequency is decreased, thereby urgency is increased. Sometimes patient gets scared to see blood in semen or urine. There is mild lower abdominal pain. Some victims experience discharge from the urethra and penis swelling. How do we diagnose? You may first notice symptoms of prostate enlargement by yourself. But your doctor may find that your prostate is enlarged during a routine check-up. Rectal Examination is usually the first test done. The doctor inserts a gloved-finger into the rectum and feels the part of the prostate next to the rectum. This gives him a general idea about the size and condition of the gland. Ultrasound may be recommended for accurate study. PSA -- Prostatic Specific Antigen -- could rule out malignancy. Stricture can be easily diagnosed by its symptoms and routine examination such as ultrasonography and cytoscopy. What treatment is advisable? Clinically stricture urethra is often noticed with prostatic enlargement. Men who have prostatic enlargement with urethral stricture symptoms, usually need some kind of treatment at sometime. Most patients ignore the symptoms until they face a "acute crisis." Early treatment is needed when the gland is just mildly enlarged. During "crisis" dilation of the urethra may be attempted. It is a procedure adopted to stretch the urethra by inserting a thin instrument. Urethral stricture may totally block urine flow, causing acute urinary retention, a condition that must be alleviated quickly. Homoeopathic medicines have wonderful power to resolve the scar tissue formation and enlargement. These are benign tumours. Their action is similar to a fibroid uterus, warts, lipoma and cancer. Homoeo medicines respond very well with non-specific urethritis and venereal infections. They also avoid surgery in maximum number of cases. I have come across few cases of prostatic enlargement and stricture urethra. The prognosis is good. I have cured a number of cases of non-specific urethritis those which were labelled as incurable. I have also cured few cases of bleeding diathesis confirmed with growth in urethral passage. Most of the victims get

scared of cancer and ask, Does it develop into a Cancer, doctor? Take treatment. Homoeopathy will cure.

I am now in my forties and have had several medical procedures performed over the years to treat the urethral strictures. In my case, I have two strictures, one is is in the anterior urethra in what is known as the bulbar urethra. The other stricture is about 3/4 of the way along the urethra. The first stricture was detected when I was a one year old, the second was most likely caused by an injury I sustained when I was six years old due to a straddle injury. I was walking on a raised railway tie and fell, straddling the railway tie. Yes it did hurt.

http://strictureurethra.wordpress.com/article/anatomy-and-pathophysiology-of-urethral-strictures/

Anatomy and Pathophysiology of Urethral Strictures

Sanjay B. Kulkarni MS, FRCS
February 8, 2012

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Mang Chen

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The male urethra is divided in to anterior part of meatus, penile and bulbar portions and posterior part of membranous and prostatic urethra. The anterior urethra is surrounded by corpora spongiosa and the narrowing of the urethral lumen due to spongiofibrosis is called a stricture. The posterior urethra is devoid of corpora spongiosa and the urethral narrowing is termed as stenosis. In the penile portion the urethra lies in the center of spongiosa and in the bulbar portion the urethra lies dorsally in the spongiosa. So dorsal urethrotomy causes less bleeding and is more popular compared to ventral urethrotomy during urethroplasty. Normal urethra is pink as the blood filled spongy tissue surrounds the urothelium. Spongiofibrosis does not allow the blood flow and urethra is white at the site of the stricture. Stricture due to trauma in the bulbar urethra can be treated by excision and end to end anastomosis as we have normal urethra on both sides of the trauma. In a non traumatic bulbar stricture, we have white strictured urethra and gray urethra between the white and pink normal urethra due to subepithelial spongiofibrosis. Anastomosis of the two gray urethras may lead to restricture formation later. The bulbar urethra has blood supply from proximal to distal end with the bulbar arteries. It also gets blood supply in a retrograde fashion through the cavernosa

in to glans and penile urethra. It also gets blood supply laterally from cavernosa through circumflex vessels. When we mobilize the bulbar urethra from cavernosa the lateral blood supply is lost. If we transect the bulbar urethra the distal portion loses its proximal blood supply. And the distal spongiofibrotic urethra already has compromised blood flow. So transection of bulbar urethra should be avoided whenever possible. Unless it is already transected by trauma. Bulbar urethra can be opened dorsally or ventrally with longitudinal urethrotomy. Ventral urethrotomy does not need mobilization of the bulbar urethra, so Asopas technique of ventral urethrotomy and dorsal onlay graft works well.
http://link.springer.com/content/pdf/10.1007/978-1-59745-103-1_6#page-1 http://gardamd.blogspot.com/2012/05/trauma-uretra_26.html

Trauma Uretra

PENDAHULUAN
Trauma saluran kemih sering tak terdiagnosa atau terlambat terdiagnosa karena perhatian penolong sering tersita oleh jejas-jejas ada di tubuh dan anggota gerak saja, kelambatan ini dapat menimbulkan komplikasi yang berat seperti perdarahan hebat dan peritonitis, oleh karena itu pada setiap kecelakaan trauma saluran kemih harus dicurigai sampai dibuktikan tidak ada.7 Trauma saluran kemih sering tidak hanya mengenai satu organ saja, sehingga sebaiknya seluruh sistem saluran kemih selalu ditangani sebagai satu kesatuan. Juga harus diingat bahwa keadaan umum dan tanda-tanda vital harus selalu diperbaiki/dipertahankan, sebelum melangkah ke pengobatan yang lebih spesifik. 7 Trauma urethra biasanya terjadi pada pria jarang pada wanita. sering ada hubungan dengan fraktur pelvis dan straddle injuri. Trauma uretra biasanya lebih sering pada anak-anak laki-laki dibandingkan dewasa yaitu pada usia sekitar 15 tahun. Urethra pria terdapat dua bagian yaitu anterior yang terdiri dari urethra pars glanularis, pars pendulans, pars bulbosa dan posterior yang terdiri dari pars membranacea dan pars prostatika. Bagian-bagian uretra dapat mengalami laserasi, transeksi atau kontusio. Penangannya berdasarkan berat ringannya trauma. 1

TINJAUAN PUSTAKA
A. ANATOMI URETRA Uretra adalah saluran yang dimulai dari orifisium uretra interna dibagian buli-buli sampai orifisium uretra eksterna glands penis, dengan panjang yang bervariasi. Uretra pria dibagi menjadi dua bagian, yaitu bagian anterior dan bagian posterior. Uretra posterior dibagi menjadi uretra pars prostatika dan uretra pars membranasea. Uretra anterior dibagi menjadi meatus uretra, pendulare uretra dan bulbus uretra. Dalam keadaan normal lumen uretra laki-laki 24 ch, dan wanita 30 ch. Kalau 1 ch = 0,3 mm maka lumen uretra laki-laki 7,2 mm dan wanita 9 mm. 3 1. Urethra bagian anterior Uretra anterior memiliki panjang 18-25 cm (9-10 inchi). Saluran ini dimulai dari meatus uretra, pendulans uretra dan bulbus uretra. Uretra anterior ini berupa tabung yang lurus, terletak bebas diluar tubuh, sehingga kalau memerlukan operasi atau reparasi relatif mudah. 2. Urethra bagian posterior Uretra posterior memiliki panjang 3-6 cm (1-2 inchi). Uretra yang dikelilingi kelenjar prostat dinamakan uretra prostatika. Bagian selanjutnya adalah uretra membranasea, yang memiliki panjang terpendek dari semua bagian uretra, sukar untuk dilatasi dan pada bagian ini terdapat otot yang membentuk sfingter. Sfingter ini bersifat volunter sehingga kita dapat menahan kemih dan berhenti pada waku berkemih. Uretra membranacea terdapat dibawah dan dibelakang simpisis pubis, sehingga trauma pada simpisis pubis dapat mencederai uretra membranasea. B. PEMBAGIAN Berdasarkan anatomi, trauma uretra dibagi atas trauma uretra posterior yang terletak proksimal diafragma urogenital dan trauma uretra anterior yang terletak distal diafragma urogenital. Hal ini karena keduanya menunjukkan perbedaan dalam hal etiologi trauma, tanda gejala klinis, pengelolaan serta prognosisnya. 1,2 Trauma uretra posterior

Male urethra

Penis with urethra

In the human male, the urethra is about 8 inches (20 cm) long and opens at the end of the penis. The urethra provides an exit for urine as well as semenduring ejaculation. The urethra is divided into four parts in men, named after the location: Region Description Epithelium

pre-prostatic urethra

This is the intramural part of the urethra and varies between 0.5 and 1.5 cm in length depending on the fullness of the bladder.

Transitional

prostatic urethra

Crosses through the prostate gland. There are several openings: (1) the ejaculatory duct receivessperm from the vas deferens and ejaculate fluid from the seminal vesicle, (2) several prostatic ducts where fluid from the prostate enters and contributes to the ejaculate, (3) the prostatic utricle, which is merely an indentation. These openings are collectively called the verumontanum.

Transitional

membranous urethra

A small (1 or 2 cm) portion passing through theexternal urethral sphincter. This is the narrowest part of the urethra. It is located in Pseudostratified columnar the deep perineal pouch. The bulbourethral glands(Cowper's gland) are found posterior to this region but open in the spongy urethra.

spongy urethra (orpenile urethra)

Runs along the length of the penis on its ventral (underneath) surface. It is about 1516 cm in length, and travels through the corpus spongiosum. The ducts from the urethral gland(gland of Littre) enter here. The openings of thebulbourethral glands are also found here. [1] Some textbooks will subdivide the spongy urethra into two parts, the bulbous and pendulous urethra. The urethral lumen runs effectively parallel to the penis, except at the narrowest point, the external urethral meatus, where it is vertical. This produces a spiral stream of urine and has the effect of cleaning the external urethral meatus. The lack of an equivalent mechanism in the female urethra partly explains why urinary

Pseudostratified columnar proximally,Stratified squamous distally

tract infections occur so much more frequently in females. The length of a male's urethra, and the fact it contains a prominent bend, makescatheterization more difficult. The integrity of the urethra can be determined by a procedure known as retrograde urethrogram. [edit]Histology The epithelium of the urethra starts off as transitional cells as it exits the bladder. Further along the urethra there are pseudostratified columnar and stratified columnar epithelia, then stratified squamous cells near the external urethral orifice. There are small mucus-secreting urethral glands, that help protect the epithelium from the corrosive urine. [edit]Length

of the urethrae

The female urethra is about 4 cm in length.[2] There is inadequate data for the typical length of the male urethra; however, a study of 109 men showed an average length of 22.3 cm (SD = 2.4 cm), ranging from 15 cm to 29 cm.[3]